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How Value Based Healthcare Embeds Clinical Negligence - Dr Mark Burgin

02/12/20. Dr. Mark Burgin BM BCh (oxon) MRCGP explains how a management theory called Value Based Healthcare (VBH) makes clinical negligence difficult to avoid.

Value based healthcare (VBH) aims to maximise a complex concept called value which is a combination of high-quality care, patient satisfaction and cost containment.

It identifies low value activities which can be reduced without needing to consider what removing that activity will do to the overall process.

The concept called ‘value’ cuts across safe practice and clinical need, to deliver what is cheap and quick whilst sacrificing what is good.

VBH is destructive to the fabric of healthcare by removing the foundations of good practice and undermining those same ‘high value’ activities which are promoted by VBH.

Rationing

Much of healthcare activity appears to be without clear purpose to patients and staff, such as documentation and senior staff doing easy tasks which could be delegated.

Removing these activities can save money without having any apparent detrimental effects to the care given to the patient, removal may be preferred by patients.

When an issue arises later due to lack of a record or the delegated task was not completed correctly there are no systems to identify the manager who created that problem.

Even where VBH is the obvious cause, the blame will typically be placed upon the individual who performed the activity rather than the system.

Needs v Wants

A patient with many risk factors may have few wants but many needs, to prevent them from developing deteriorating medical conditions.

Alternatively a patient with chronic pain may have many wants but there may be little that medicine can do and there is a risk of excessive medicine.

VBH measures how rather than what care is delivered and patient satisfaction, which are both more about wants than needs thus distorting priorities.

Worse still is that the pressure to help the patient with wants means that the doctor will try increasingly risky treatments until something goes wrong.

What is value?

Any measure that is flexible enough to include these three components will be easy to game, making it unreliable as a measure and eventually self-serving.

Compared with ‘clinical need’ (which has been at the heart of healthcare for decades) it is less clear that ‘value’ is a universal good that should be prioritised.

Patients rely on their doctors to make the difficult choices and trust that they will do what is necessary, even if it is expensive or will not give patient satisfaction.

True value is the balance point between the doctor’s view, the patient’s view and what is possible given medical science at the time.

Conclusions

Doctors should consider what they value more, measures that make it easier for managers to control or measures that reflect clinical outcomes for their patients.

Resisting systems that encourage poor clinical practice is only possible if doctors understand what the managers are doing and leaders speak out to challenge it.

When a practitioner stands alone, the system will punish them to make them comply or leave and no one will listen to what they have to say.

If a practitioner is focused upon ‘value’ they will not be considering what their patient needs to keep them safe in a system depleted by cost containment.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register and audits medical expert reports.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

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